Therapeutic Exercises & Functional Training

Jose Bonifacio S. Rafanan M.D.Fellow, Philippine Academy of

Rahabilitation Medicine

Outline Definition: Concepts in therapeutic exercises Benefits of exercise Local and systemic effects of

exercise Types of exercises Components of exercises Parameters of exercises Forms of exercises Facts and fallacies about exercise

Therapeutic exercise

Exercise: Muscle being used in some type of

exertion causing motion of parts of the body

Therapeutic: Exercise as a part of a treatment

program under medical supervision and appropriately prescribed by a physician

Benefits of exercise

Lifetime health and fitness benefits Increase in high density lipoproteins Decrease in triglycerides Improved lung function Helps reduce blood pressure, anxiety and

depression Control weight Increase the body’s ability to dissolve blood

clots by increasing fibrinolytic activity Increase levels of endorphins Helps the bones to be stronger – inhibiting

osteoporosis Offers protection against diabetes and cancer

Concepts in Exercises: Overload Principle:

Greater stress must be applied than that to which an organism or tissue is accustomed in order to have adaptation take place

Strengthening program must tax muscle groups towards it maximal capacity and beyond its usual functional capacity

To increase strength, a load that exceeds the metabolic capacity of the muscle must be used during exercise, this will lead to hypertrophy and recruitment resulting in increase in strength

Concepts in exercise

Adaptation Cardiovascular system and

muscles adapt to the training stimulus over time

Significant changes noted in 10 – 12 weeks

The higher the initial level of fitness, the greater the intensity of exercise needed to elicit a significant change

Concepts in Exercise

Reversibility principle: Beneficial effects of exercise training are

transient and reversible After only two weeks of detraining,

improvement begin to be lost Frequency and duration of physical

activity needed to maintain a certain level of aerobic fitness is less than that required to improve it

Concepts in Exercise

Specificity of training: Exercise adaptations are directly related

to the nature of the exercise stimulus No strength training program will give a

100% carry over to a sporting or functional activity unless the specific sports or functional activity makes up the training program

Adaptive effects of training are highly specific to the training methods used

Effects of exercises

Acute or immediate effects Chronic, adaptive or training

effects

Local effects Systemic effects

Acute Effects

Start of exercise:increase heart rateincrease cardiac outputIncrease in blood pressureincrease in venous returnincrease in arterio- venous O2

difference

Systemic effects

In isotonic exercises decrease peripheral vascular

resistance increase in muscle blood flow

In isometric exercises Decrease in local blood flow to the

contracting muscles Increased blood pressure

Systemic effects As exercise continues at constant rate:

Steady State: heart rate Blood pressure

Cardiac output• At the end of exercise:

• Initial rapid drop in heart rate then slower return to normal

• Decrease in blood pressure sudden if exercise is stopped abruptly

Systemic effects

If exercise is greater than the body’s ability to maintain: Heart rate plateaus at maximal level Decreased stroke volume, arterial

blood pressure Constant O2 consumption

Fatigue sets in

Systemic effects respiratory effects:

Respiratory rate increases: 5 – 6 times in maximal exercise

Tidal volume increases: 5 – 7 times Hormonal effects:

Decrease insulin production Increase glycogen production Increased catecholamine, in intense exercises Increase in growth, adrenocorticotrophic,

TSH, adrenal and androgens

Systemic effects

Post exercise syncope Seen after vigorous exercise Pooling of blood in the exercised

extremity Hypotension Catecholamine release – risk of

developing dysrhythmia, cardiac ischemia

Systemic effects

Arm exercises vs. leg exercises: Higher systolic and diastolic blood

pressure Higher heart rate Higher oxygen uptake

Exercise should use workload 40 – 60 % lower than those used for LE in order to obtain systemic effects

Local effects

In the muscles being exerted: Increased oxygen extraction Increased oxygen consumption Increased carbon dioxide production vasodilatation

Local effects

During isometric contraction: Complete occlusion of blood flow 70% of maximal voluntary contraction

level Depletion of energy substrates

During isotonic exercise: Slow twitch fibers first to lose glycogen

then followed by the fast twitch fibers

Parameters of exercise

Mode of exercise: Aerobic vs. anaerobic exercise

Intensity of exercise Duration of exercise Frequency of exercise

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COMPONENTS OF EXERCISE

PRE EXERCISE WARM UPPRE-EXERCISE STRETCHING

EXERCISE PROPERPOST EXERCISE COLD DOWNPOST EXERCISE STRETCHING 1

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PURPOSE OF WARM UP

to raise the general body temperature to raise the deep muscle temperature - contracts more forcefully and relaxes more

quickly to stretch collagenous tissue to reduce muscle viscosity, improving the mechanical efficiency to increase the speed of nerve impulses and augment the sensitivity of the nerve

receptors to improve the cardiovascular response to sudden exercise

2

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TYPES OF WARM UP RELATED WARM UP

when the specific skills of an event are performed during the warm up

preferred if activity starts slowly and progresses into more intense activity

UNRELATED WARM UP when movements performed are different

from the actual skills of the activity or event preferred if immediate participation in the

actual activity is required 3

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WARM UPS

15 - 20 minutes intensity and duration should be

individualized enough to increase body temperature

and perspire, not too intense to cause fatigue

usually coupled with few minutes of high intensity exercise to result in better performance 4

Warm up

the effects of warm up last up to 45 minutes the closer the warm up to the event, the

more beneficial it will be in terms of effective performance

should begin to taper off 10 - 15 minutes prior to the training or competition/ event

should end 5 minutes before the start of activity - to allow recovery from fatigue

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STRETCHING

GOAL: to improve the range of motion at a given articulation by altering the extensibility of the musculotendinous units that produces the movements

5

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TYPES OF STRETCHING

BALLISTIC STRETCHING STATIC STRETCHING PNF STRETCHING PASSIVE STRETCHING ACTIVE STRETCHING

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BALLISTIC STRETCHING

requires repetitive contraction of the agonist muscle to produce quick stretches of the antagonist muscles

ADV: simulate sports specific skills - functional

7

Ballistic stretching

DISADV: predispose to muscle strain rapidly stretched muscle may increase

intrafusal muscle spindle activity causing protective muscle contraction

higher level of muscle soreness due to small tears in connective tissues and muscles

fails to provide tissues an adequate time to adopt to a stretch

should be done after a static stretch

STATIC STRETCHING passive or active stretching a given

antagonist muscle by placing it in a maximal position of stretch and hold it for an extended time

3 seconds to 60 seconds three to four times

Static stretching

ADVANTAGES: requires lesser energy expenditure lesser degree of exceeding normal range of

motion less muscle soreness allow adequate time to reset the sensitivity

of the stretch reflex can induce muscular relaxation via firing of

the GTO if the stretch is held long enough

PNF STRETCHING

AKA: muscle energy release technique

techniques: contract - relax contract - relax - contract

commonly used with athletes and individuals with limited range of motion

TYPES OF STRENGTHENING EXERCISE

ISOMETRIC EXERCISES ISOTONIC EXERCISES ISOKINETIC EXERCISES

Types of exercise

Isometric exercise: Static exercise with

muscle contraction but no movement of the load resulting in no change in the total length of the muscle

Type of exercise

Isotonic exercise: Dynamic exercise

with a constant load but uncontrolled speed of movement

Type of exercise

Isokinetic exercise: Exercise with movement

controlled so that it occurs throughout a range at a constant angular velocity as the muscle shortens or lengthens but the load may be variable

Exercise goals

To increase muscle strength To increase muscle endurance To increase speed To improve cardiovascular fitness To improve flexibility To improve control and

coordination

MUSCLE STRENGTH AND ENDURANCE

STRENGTH: ability of the muscle to generate force against some resistance

ENDURANCE: ability to perform repetitive muscle contraction against some resistance of an extended period of time

POWER: large amount of force generated quickly; includes elements of strength and speed

CLOSED KINETIC CHAIN EXERCISES

ADV: safer and produce stresses and forces that are potentially less of a threat to healing structures

e.g. mini squats - 0 - 40 degrees leg press stair climbing lateral step up push ups , chin ups hand stands weight shifting exercises using medicine

balls

CARDIOVASCULAR ENDURANCE

CONTINUOUS TRAINING imposes submaximal

energy requirement that is consistent throughout the training session

e.g. aerobic/ rhythmic walking, jogging, rowing, cycling, swimming

Cardiovascular endurance

INTERVAL TRAINING uses a series of exercise stations that

consists of various combinations of weight training, flexibility, calisthenics, brief aerobic exercises

CARDIOVASCULAR ENDURANCE

CIRCUIT TRAINING followed by relief stations

incorporates work intervals FARTLEKTRAINING

types of cross country running, means speed play, similar to interval training

PLYOMETRIC EXERCISES: exercises that encompasses a rapid stretching

of muscle eccentrically, followed by a rapid concentric contraction

the greater the stretch before concentric contraction, the greater the resistance the muscle can overcome

emphasize the speed of the eccentric phase of rate of stretch is more critical than the magnitude of the stretch

Plyometric exercises

ADV: control in dynamic movements DISADV: put more stress on the MS

system, must be technically correct and specific to one’s age, activity and physical and skills devt.

TRAINING PERIODIZATION

MACROCYCLE - yearly ( 1 - 4) MESOCYCLE - months MICROCYCLE - weekly

PREPARATION PERIOD ( pre season) TRANSITION PERIOD (basic strength phase) COMPETITION PERIOD ( strength and power phase) TRANSITION PERIOD ( peak or maintenance phase) ACTIVE REST ( off season )

PREREQUISITES FOR PLYOMETRICS

DYNAMIC VERTICAL/ SINGLE LEG JUMP LONG JUMP EQUAL TO HEIGHT

STATIC single leg stance single leg 25% squat single leg 50% squat UPPER EXTREMITY THERABALL

TOSS

CATEGORIES OF PLYOMETRICS

IN PLACE JUMPING STANDING JUMPING MULTIPLE RESPONSE JUMPS AND HOPS IN DEPTH JUMPING AND BOX DRILLS BOUNDING HIGH STRESS AND SPECIFIC SKILLS

Functional training

Consists of evaluating the functional independence level of a physically handicapped individual and assisting the individual in gaining the highest practical level of independence in daily living activities

Areas in activities of daily living

Feeding and grooming Sitting/ standing

balance and tolerance Bed mobility and

transfers Perineal care and

hygiene Ambulation Dressing

FALLACY:

SPOT REDUCTION CAN REDUCE THE AMOUNT OF FAT IN CERTAIN PARTS OF THE BODY

FACTS

EXERCISE, EVEN WHEN LOCALIZED, DRAWS FROM ALL OF THE FAT STORES OF THE BODY

DECREASE IN GIRTH IS A RESULT OF INCREASE IN MUSCLE TONE

HIGH INTENSITY AEROBIC EXERCISES USES 65% OF THE BODY ENERGY STORES WHILE LOW INTENSITY EXERCISES USES MORE FAT AS AN ENERGY SOURCE BUT IT DOES NOT NECESSARILY LEAD TO A GREATER EXPENDITURE OF CALORIES

FALLACY EXERCISE AND SPORTS

WILL DETER BONE GROWTH IN CHILDREN

FACTS

EXERCISE AFFECTS PRIMARILY BONE WIDTH, DENSITY AND STRENGTH BUT DOES NOT AFFECT THE BONE LENGTH

EXERCISE ALONG WITH ADEQUATE DIET IS ESSENTIAL FOR PROPER BONE GROWTH

SPORTS ONLY CONTRIBUTE TO ABOUT 23% OF EPIPHYSEAL INJURY IN CHILDREN

COMPETETITVE BASEBALL, TENNIS AND SWIMMING CARRY HIGHER RISKS FOR SHOULDER INJURY IN CHILDREN

FALLACY

WHEN A FAT BABY GROWS UP, BABY FAT WILL DISAPPEAR

FACTS

FAT BABIES MAKE FAT ADULTS FAT CELLS ARE FORMED DURING

THE FETAL DEVELOPMENT UP TO DEATH

FAT HYPERPLASIA OCCURS WHEN EXISTING FAT CELLS CONTINUE TO FILL WITH FAT TO A CERTAIN CRITICAL VOLUME

FALLACY

STRENGTH TRAINING IS CONTRAINDICATED IN CHILDREN

FACTS

PREPUBESCENT CHILDREN CAN IMPROVE STRENGTH WITH RESISTANCE TRAINING DUE TO SYNCHRONIZATION OF MOTOR UNITS FIRING. IT IS ONLY DURING PUBESCENT PERIOD THAT INCREASE IN STRENGTH IS DUE TO INCREASE IN MUSCLE MASS

RESISTANCE TRAINING IS ALLOWED IN CHILDREN WITH THE PROPER GUIDANCE OF A TRAINED WEIGHT TRAINOR

FALLACY

THERE IS AN INCREASE IN METABOLIC RATE AFTER EXERCISE ( EXCESSIVE POST EXERCISE OXYGEN CONSUMPTION) REGARDLESS OF THE TYPE OF EXERCISE.

FACTS

E.P.O.C. IS INCREASED DEPENDING ON THE INTENSITY OF EXERCISE

FALLACY

SOME HEALTH FADS ARE MORE EFFECTIVE THAN OTHERS

FACTS

THE MOST IMPORTANT FACTOR IN WEIGHT REDUCTION IS THE DEVELOPMENT OF A CALORIC DEFICIT WHILE MAINTAINING A COMPLETE BALANCED DIET THAT MEETS THE BODY VITAMINS AND MINERAL REQUIREMENT

FALLACY

DIET AND WEIGHT RESISTANCE TRAINING ARE THE BEST COMBINATION IN DECREASING BODY WEIGHT.

FACTS

DIET AND AEROBIC EXERCISE DECREASES BODY WEIGHT AND PERCENTAGE BODY FAT BUT MAINTAINS FREE FAT MASS

FALLACY

EXERCISE IS AN APPETITE STIMULANT

FACT

EXERCISE APPEARS TO BE A MILD APPETITE SUPPRESSANT FOR THE FIRST FEW HOURS FOLLOWING INTENSE EXERCISE TRAINING DUE TO AN INCREASE IN CATECHOLAMINE

THANK YOU VERY MUCH